Rick Brooks, Rhode Island’s Director of Healthcare Workforce Transformation: Creativity Born of Crisis

Van Ton-Quinlivan:  Welcome to WorkforceRx with Futuro Health, where future-focused leaders in education, workforce development and healthcare explore new innovations and approaches. I’m your host, Van Ton-Quinlivan, CEO of Futuro Health.

Nearly all of the issues we talk about on this podcast that relate to improving healthcare — from reducing racial inequities to increasing access to home care services and many others — depend on solving workforce problems. That’s why it’s safe to say my guest today, Rick Brooks, has his hands full as Director of Healthcare Workforce Transformation in Rhode Island’s Executive Office of Health and Human Services. Boy, that’s a long title there for your business card, Rick.

In that role, Rick has responsibility for developing plans, policies, programs, and partnerships that align healthcare workforce education and training with the needs of healthcare providers and the state’s health system transformation goals. Rick has spent more than 30 years as a labor educator, advocate and organizer, including roles leading the state’s largest healthcare union and the governor’s workforce board, so I’m looking forward to getting his richly informed views on these issues.

Thanks for joining us today, Rick.

Rick Brooks: Thanks so much, looking forward to our conversation.

Van Ton-Quinlivan: Delighted to have you. Let’s get started by having you set the table and give us a general sense of the healthcare workforce challenges in Rhode Island right now, and which challenges presenting the bigger problem.

Rick Brooks: Sure, where to start? There are many and I don’t think that Rhode Island is all that unique in that regard. If I had to reduce it to a single word, I guess I would say shortages. I often talk as well about the need for a greater workforce capacity and greater workforce diversity, and that’s across all settings and all occupations.

There’s a lot of reasons for the workforce challenges that we have and the shortages that we’re facing. It boils down to recruitment and retention. People often associate it with the pandemic, but really the pandemic just exacerbated what we were already dealing with and what was coming down the tracks towards us.

The first piece is really working conditions. It’s not easy working in healthcare. The pressure, the physical and emotional toll that the work takes on workers in all roles creates a lot of burnout, and that in turn leads to high rates of turnover. In addition, in many roles, the jobs can be dangerous. Certainly during the pandemic, there were increased risks of infectious disease.

The hours are often undesirable or unpredictable. Many healthcare jobs, of course, require folks to work all three shifts and weekends and that’s often a challenge for working parents and that was even more the case during the pandemic as well, when students were not able to attend school and were home and just balancing work and family became even more difficult. As we know that led to what we now refer to as the ‘great resignation’ and folks who were perhaps getting close to retirement accelerated their plans a bit and others who maybe were new to the field or thinking about the healthcare field maybe thought again and took a look at it and said, you know, in some of the jobs — particularly the unlicensed or paraprofessional roles — the wages and benefits are not great, there’s not a great deal of respect and recognition, the advancement opportunities are often limited.

And even for the licensed health professionals, there were a lot of issues around — and are a lot of issues around — reimbursement rates, compensation, particularly for those providers who serve Medicaid beneficiaries, very high caseloads, burdensome paperwork…all of those things that have combined to cause people to either leave the field or not enter the field at the rates that we need them.

In addition, there are some general labor market trends. We talk about the great resignation but there’s also really structural shortages at this point due to the population boom and bust. We’ve seen people aging out of the workforce and not being replaced in the same numbers that they’re leaving. It’s a tight labor market. Unemployment in Rhode Island is around three percent. That’s historically low and that means workers have a lot of choices. And again, particularly in the lower wage healthcare occupations, people are thinking twice and thinking about work-life balance, as I said, and other opportunities outside of the healthcare field.

Then one other challenge of course, is that to fix these issues requires money. During the pandemic with the CARES Act and then the Rescue Plan, there was a lot of money that came into states that has largely been used here in Rhode Island, and I’d say in most places, for one-time fixes. That’s understandable because it was one-time money. So, a lot of money got put into trying to stop the bleeding, encouraging folks to stay in their jobs with retention bonuses and other incentives.

There were hiring incentives as well in many cases and other ways that the funds were used to try to reward and recognize people who were working through the pandemic and working in healthcare. But those funds are starting to dry up and the pressure is returning to state budgets to pick up the slack. And certainly in Rhode Island, that’s a real challenge. There are many, many areas that are going to be strained as pandemic dollars disappear. That translates in healthcare into challenges to compete with other states and other sectors besides healthcare for employment and careers. So, that’s some of the challenges that we’re facing.

Van Ton-Quinlivan: Well, that’s an excellent overview of the challenges being faced by Rhode Island, but as you mentioned, it’s also shared by most other states. I’m wondering, in your perspective, is there a light at the end of the tunnel? What workforce  practices and strategies in Rhode Island are holding the most promise for you at this moment?

Rick Brooks: Sure, well, I think I’d like to tell you a bit about the statewide initiative that we’ve undertaken here and have been doing actively for at least the last year and a half. Back in the very early part of 2022, all these challenges that I was just describing were becoming almost insurmountable. Naturally, the elected officials and state agencies that fund and oversee and support providers were feeling the need to respond to those pressures that providers were facing. So, we at the Office of Health and Human Services took the initiative to reach out to partners in state government, in particular our Office of the Postsecondary Commissioner, which is our higher education agency, and our Department of Labor and Training, because those are the two workforce training agencies and we bring the health and human services perspective. We approached them and said this is everybody’s challenge, this is everybody’s responsibility let’s put together a process and bring together partners from the private sector and see what we can do.

With the governor’s blessings, of course, we reached out to all sorts of private sector partners, ranging from direct healthcare provider agencies to higher education institutions, community-based organizations that do training, adult education, advocacy, trade associations, professional associations, labor unions, insurers…pretty much any organization that has a connection to healthcare responded.

We reached out and they responded because it was such a huge issue and people were looking for an opportunity to get together and both share their frustration but also more importantly work on solutions. So, we started that effort in the spring of 2022. Since that time we’ve had over 500 individuals participate in our planning work from 160 plus organizations. By Rhode Island standards, that is a lot. We set out to tackle both short-term issues that we felt we could make a difference on relatively quickly, and also recognize that there were longer-term systemic challenges that we couldn’t do overnight, but that we would begin to identify and tackle as well.

I would say those initiatives fell into a few broad categories. One was focused on career pipelines and pathways. Another was higher education partnerships. Another was data. And then in the longer term, of course we knew we were looking at the potential of needing additional budgetary or policy or statutory changes that would require the General Assembly’s support as well as the Governor’s.

So, let me give you some examples of the initiatives that we’ve worked on, and then I’ll perhaps get into more detail about some of them. In the world of higher education, we’ve been looking at ways to expand and promote access to health professional loan repayment programs and also expanding clinical placement opportunities. As you know, health professional students need to get hands-on clinical experience and that can be a real challenge for schools to find the placement sites and for the placement sites to be able to support students, especially when they’re strapped. This is especially true in community-based settings where they don’t have a dedicated teaching staff so they have to pull folks out away from patients at times to provide supervision or precepting for students, and that creates financial and other pressures on those agencies.

In the area of career pipelines and pathways, we’ve been doing a lot of work, including some social media and other activities, focused on increasing awareness of healthcare job and career opportunities, reaching out to students, reaching out to folks who are maybe new to the country, new to the workforce, to encourage folks to consider jobs and careers in healthcare.

We’ve partnered in particular with career and technical high schools, bringing them together with healthcare agencies to make those connections for their students to learn about career opportunities and get the training that they would need.

We’re doing a lot around pre-employment training. We’re supporting our Department of Labor and Training to do free employment training but also career ladder development, apprenticeship programs, continuing education for folks that are already in the workforce but maybe at the entry levels.

We’re also supporting something called the Welcome Back Center which is an initiative you’ll be familiar with. We have one in Rhode Island, and there are a number around the country. Ours had been dormant for a while. This is a program that supports foreign trained health professionals to get through the recredentialing process, in some cases the English language proficiency and other maybe educational components that they need to obtain a license and be able to work in their chosen profession.

We’ve also entered into a partnership with our Office of the Postsecondary Commissioner using ARPA funds to create what we call a health professional equity initiative. That is specifically focused on supporting paraprofessionals working in home and community-based services essentially to increase the capacity of those agencies.  There’s an entire workforce of relatively low-paid, direct-care workers who don’t hold professional licenses and are disproportionately people of color — unlike the licensed occupations, which are disproportionately not people of color — and so we set out to create this health professional equity initiative, which is providing significant tuition assistance, as well as an array of other supports, for paraprofessionals to return to school to get a higher education degree in a health profession and obtain their license. That’s been in the works for about fifteen months and we have over 100 people in that program.

We’re also looking at regulatory reforms and working with partners in the private sector to identify ways to remove regulatory barriers to education and employment. I’ll talk a little bit more about that later, but that could be requirements for training, for testing, for credentialing, scope of work, those sorts of things.

Then there’s our data capacity in Rhode Island. Until this past year, we only knew how many licensed professionals we had, but we didn’t know anything more about them, really. We didn’t know if they were working in Rhode Island or where they were working in Rhode Island; we didn’t know much, if anything, about their demographics; we didn’t know about their earnings; we didn’t know how many were going out of state or working in other settings besides healthcare.

We created a data sharing agreement between our Department of Health’s Licensure Division and what we call here in Rhode Island our data ecosystem. That system brings in lots of information from more than twenty different data sources including our Department of Labor wage records as well as a number of sources that have good demographic data. We’re able, through the magic of data matching, to be able to have a much better picture of who is in our workforce and where our gaps are.

Lastly, in the past six months, we’ve developed some of the budgetary and policy initiatives that will require legislative action and gubernatorial support and those will be getting underway in the next month and the coming year. It’s a lot.

Van Ton-Quinlivan: Well, Rick, you’ve been busy and my head is on fire with a set of follow on questions. First, I wanted to say congratulations on getting 160 organizations involved in this initiative. I’m very curious about the insurers that you mentioned. What was the conversation like to bring insurers and payers to the table?

Rick Brooks: Yeah, well, in some settings, insurers are quite concerned. Speaking of home and community-based services, some of our insurers, especially the managed care organizations, are concerned because they bear some risk if individuals who could be cared for in community settings are compelled to go into institutional settings or can’t be transferred out of institutional settings when ready because of workforce shortages. For example, if our home care agencies don’t have sufficient staff or if we don’t have enough community-based behavioral health services, which winds up causing people to land in the ERs or be hospitalized when they may not need to be. So, those are from just the perspective of cost avoidance. Those are issues that are of concern to insurers.

Van Ton-Quinlivan:  Another follow-on question, Rick. You talked about loan repayment programs. I’m on the California Healthcare Workforce Education and Training Council and we’re looking at restructuring financial aid. I’m wondering how you are rethinking loan repayment programs over in Rhode Island.

Rick Brooks: There’s been a number of approaches. The most basic approach is simply to add state funds into the pool of state loan repayment resources because currently there are no general revenue funds going into that pool. The funding is only from the private sector — from insurers and from our major philanthropic foundation in the state — so that’s step one, to get a state allocation to that if possible. There are some other proposals out there from advocates to create state funding for scholarships which is different from loan repayment, as you know, because it’s sort of the front end as opposed to the back end support.

We also have a unique tax credit program here called the Wavemaker Fellowship which was originally started to encourage recent college graduates to work in Rhode Island who had training in primarily STEM occupations, but that was expanded a year or two ago to include healthcare occupations of all sorts. So, that is yet another approach to reducing the cost of higher education.

Van Ton-Quinlivan: And then of course on everyone’s mind are clinical slots, which is the bane of everybody’s existence. Do you have any creative strategies for increasing clinical slots?

Rick Brooks: Well, there’s been a lot of conversation and a number of different ideas bounced around. There is an advocacy organization that works closely with primary care providers that has been very vocal about the costs that are incurred by community-based providers when they take in a student to supervise. And of course, there are disparities amongst different occupations and schools. Some schools and some professional programs are able to pay providers for clinical placement sites and others are not. Most of our public programs are not able to pay providers and that puts them at a disadvantage and those are the same programs from which we have the highest retention rate.

In other words, graduates of our state community college and university are more likely to stay and keep working in Rhode Island, and yet they don’t have the resources in most cases to pay for clinical sites. So, there is a proposal to try to find some public funds to support clinical placements.

Van Ton-Quinlivan: You mentioned in your remarks that there’s a concentration of diversity in certain areas of the healthcare workforce, and they tend to be the lower paid ones, and then not much so in other sets of occupations. So, given that diversity in the healthcare workforce is a key priority of the executive office of Health and Human Services, what do you think are the biggest barriers to achieving this level of inclusivity that you’re hoping to attain?

Rick Brooks: Yeah, I mean the barriers are numerous, I’m sorry to say. I mean, disparities exist at all levels, in all components of society. It’s quite systemic and very ingrained and we need very, very proactive initiatives at all levels of education and workforce. I think we need potential healthcare workers — whether youth or adults — we need to have direct outreach, new messages, new models, new mentors that encourage all potential healthcare worker students and workers to see themselves in new roles and to be encouraged and supported to aspire to roles that they might not have imagined. And we need to have the supports in place to make that possible. So, we need tuition assistance, we need that outreach, we need mentors, we need role models, we need culture change in our schools and in our workplaces that, like I said, send the message that everybody can do this, everybody will be supported to do this. These are not jobs or pathways just for one ethnicity or race, but that we need everyone and we will work to make that happen. That requires a sustained commitment and a genuine commitment. Not easy.

Van Ton-Quinlivan: Not easy. Well, Rick, you and I met at the National Governors Association convening. I am curious, what’s the situation in Rhode Island for your governor and your state legislature specific to the mental and behavioral health workforce shortages? I’d love to hear your thoughts on that, and on any policy wish list.

Rick Brooks: I mentioned the loan repayment. We’re hoping for funds for that, as well as some of the advocates that are looking for other ways to support clinical placements, particularly for behavioral health and primary care as well. There have been a number of rate reviews undertaken in the past six months. There’s been a general awareness that Rhode Island’s rates, both Medicaid and commercial rates, are not competitive with our neighboring states.

We have in Rhode Island an Office of the Health Insurance Commissioner — I think we may be unique in the country in that — and that office was charged with doing a rate review of behavioral health and a number of other services and they did issue a report a couple of months or so ago that acknowledged some very significant rate shortfalls or disparities, and so that will be a major focus, I’m sure, of the budget deliberations over the next legislative session.

We’re also trying to create and hoping for support for an additional career ladder initiatives sort of based on the health professional equity initiative I was describing, but to broaden it so that it isn’t limited just to home and community-based services. We want to expand it beyond those settings and also to make it more systemic in its approach. It would encourage, and almost require, partnerships between employers, partnerships between employers and schools, partnerships among schools to create some system changes that really will facilitate advancement from paraprofessional to licensed occupations.

Van Ton-Quinlivan: So, Rick, knowing all that you know about what’s going on in healthcare and all of its shifts and changes and pressures, let’s say you are advising your niece or nephew on the labor market and how to prepare for the world of work. Can you identify any skill sets that are in demand now or will be in the future? What guidance would you give, Rick?

Rick Brooks: Sure, well for starters I would say healthcare is changing, the world is changing, health systems are changing, and whether folks are looking to become a licensed clinician or some other role that might not require a license, I think there are some common things that are already important and will continue to be increasingly important.

There really needs to be increasingly a focus on and an awareness of the role of social determinants of health, first of all. Medicine historically has focused on treating disease very episodically. Somebody gets sick, they come in, they get a medication or whatever, a procedure, they go home, they get sick again, and that continues to happen. We’re less set up to address the underlying reasons that folks get sick.

We know that many of the reasons that people become ill or have chronic diseases are not due to their lack of access to healthcare or what kind of healthcare they have, but rather to all sorts of other social factors, like their housing, their nutrition, their lifestyle, their genetics, risks in the communities that they live in and all sorts of things like that, and of course poverty more than anything.

So, as healthcare providers are increasingly paid not just for every service that they provide — which is a volume based approach — but rather for outcomes — which is value-based —  they are coming to see that they need to pay attention to those underlying causes of illness because otherwise they will bear a portion of those costs. And so it’s actually a win-win. If they take a different approach, population-wise we will have healthier people and we will also hopefully be able to control our costs better. So, for somebody entering the workforce, that means they need to be aware of the role of social determinants of health and also be aware of what value-based payments are and providing care that is focused on wellness and prevention rather than just volume of care.

We need to have more people going into the workforce at all levels of the ladder who have lived experience, who are diverse culturally, linguistically, racially and can relate to the populations that they serve. That means specific jobs that do that — such as community health workers or peer recovery specialists — who do that navigation, do that advocacy for patients, but increasingly we need that across all occupations. That’s an essential skill set and knowledge set, whether you’re a case manager, social worker, other kind of behavioral health professional, or a nurse or a physician — anybody who has direct interaction with patients.

Van Ton-Quinlivan: You mentioned value-based care and its outcomes, the attention to social determinants of health and going upstream. Your career has included tenure in the labor movement so I’m curious how do the unions receive these principles, these concepts that you’ve just laid out?

Rick Brooks: It’s a good question and I would say it depends. I think with healthcare unions, like many unions, their first priority is to address the immediate needs of their members. That tends to be contract-focused, negotiations-focused, grievance-focused, working conditions-focused. However, I will say — and certainly in my role as a healthcare union leader, I understood and I think most healthcare units do understand — that it’s not the same as representing workers who work for a supermarket or truck drivers. We’re talking about work and a mission that impacts people’s lives in very direct ways.

This is where I think the opportunity comes in for healthcare unions, that there’s a shared interest, a mutual interest between patients and healthcare workers if there’s a consciousness to find that shared interest. So, as you know, in California, the nurses unions out there are very vocal about staffing ratios and the like, particularly in hospitals, but also training and education and professionalizing the jobs that their members do. I think that’s something that is not only beneficial to the members, but also to the patients that they provide care and services for. So that’s where I think there is an intersection.

In my experience, healthcare unions have been a little less focused on workforce development, particularly for those who are not in the workforce. Continuing education and professional development for their members is something that some healthcare units focus on, but some have not been as focused on the needs of people who are not yet in the healthcare workforce.

Some are, however, and as I think you know, in my former union, we partnered with the two largest healthcare systems in Rhode Island, with another union, with a couple of major community-based organizations that provide adult literacy services — particularly to immigrant populations — and we put together a program called Stepping Up. There was a lot of mutual self-interest there, as well as a lot of vision and passion to do the right thing.

We were able to bring the hospital systems into partnership with the unions because the hospitals at that time, not unlike now, were facing significant nursing shortages and were spending a fortune on travel nurses and also spending a fortune on overtime, both voluntary and mandatory overtime. That mandatory overtime is extremely unpopular with union members as you would imagine, and so were travelers who were receiving far more money or at least their companies were receiving far more money. So, nobody liked travelers, neither the union nor the employers and nobody liked forced overtime.

And at the same time, we were well aware that there were folks in the community who with the right supports could be filling these jobs and folks within our own ranks. The hospital, quite frankly, didn’t have the best image with the community that it sat within – it knocked down a lot of homes over the years to put up buildings and parking lots — and so they joined with us and we created this Stepping Up program and we partnered with two community-based organizations and we developed this approach to move folks into the entry-level jobs and move folks up from those entry-level jobs. We brought classes onto the hospital campuses as well as the college campuses. So, that’s the kind of thing we’re still looking to do.

I’ll add one other thing: the state is also more aware of and sensitive to working with unions and I would say more broadly one of the things that I see happening, and I think this is sort of exciting, is that ‘never waste a good crisis’ mindset, and certainly we have a workforce crisis. One of the benefits that’s coming out of that, oddly, is that strange bedfellows are coming together. We actually have an effort that is just in discussion right now, but I can tell you that there are some discussions going on between the healthcare unions and the hospital association looking at ways to partner around healthcare workforce development.

There are partnerships happening between schools, higher education programs that, you know, have traditionally viewed each other as competitors, considering articulation agreements. Even the academic and the non-academic sides of the house within the same higher education institutions which have historically not necessarily collaborated very well are recognizing the need to develop  agreements that grant credits for non-credit activities.

On the regulatory side, I mentioned trying to address barriers to licensure and to education. We’re seeing our licensure boards more open to rethinking the education requirements for nursing faculty, for example. Or to get more creative about ways foreign trained health professionals can get recredentialed in this country or in our state. Being more open to online training and testing or maybe even testing in languages other than English.

Here’s an interesting example I heard just yesterday that I learned in a conversation with the Welcome Back Center talking about how in Massachusetts they have a program and policy that allows foreign trained dentists to get experience in Federally Qualified Health Centers with supervision from dentists. And if they meet those experiential and supervision requirements, they don’t have to return to a full dental program as they would otherwise have had to do, and as they have to do in Rhode Island. We’re going to explore the possibility of bringing something like that into Rhode Island.

So, I think that because of the crisis, there is more creativity and more willingness to be innovative.

Van Ton-Quinlivan: Well, that’s a good advice to never waste a crisis.

Rick Brooks: (laughs)

Van Ton-Quinlivan: It’s unlocking all sorts of creativity, and especially that ‘welcome back’ for dentists. I know that the average debt of a dental school graduate is $240,000, so the accelerated path that you’re talking about is certainly welcome to fill some of those hard to find roles. So Rick, let me end with the question of what makes you optimistic about the future of care?

Rick Brooks: I think what makes me optimistic is the level of engagement, for sure. There’s tremendous interest and consensus around the fact that we have real problems, and I think some consensus around solutions. The strange bedfellows, the new partnerships, I think are really encouraging. And I would say in particular — and this may be more aspirational but I’m still motivated by it — is the increased recognition of the importance of career ladders.

For us, we think of career ladders in a number of different ways. One is bringing people into the workforce, and I talked a little bit about partnerships with career and technical programs and other programs that are pre-employment. And then there are career ladders within occupations and from occupations. By that I mean that  oftentimes we say that the next step on the ladder for a nursing assistant is to become a nurse, and we know that that’s a very large leap. It’s a great thing when it happens, but there need to be ladders with rungs that are more achievable, closer together and that means career ladders that enable people to stay within their field.

They might be a nursing assistant, they might be a medical assistant, they might be a case manager, where they can become a level one, two, or three with corresponding skills, training, credentials, compensation, responsibilities, etc., so that folks can grow within those occupations and don’t leave as readily as they do now, where we have very high turnover in those occupations.

And then also, yes, ladders with the right supports for folks to continue on to obtain a professional degree, like a registered nurse or like a social worker, for example, on the behavioral health side.

So those are, I think, encouraging developments. We’re seeing progress, we’re seeing partnership, and I think we can make something out of this crisis.

Van Ton-Quinlivan: Thank you very much, Rick Brooks, for joining us today. We learned a lot about what’s going on in Rhode Island and about your thinking and learnings that could be applied everywhere else.

Rick Brooks: Good. Well, thank you for the opportunity to talk with you. I appreciate it.

Van Ton-Quinlivan:  Absolutely. I’m Van Ton-Quinlivan with Futuro Health. Thanks for checking out this episode of WorkforceRX. I hope you will join us again as we continue to explore how to create a future-focused workforce in America.